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A28 67c_ � The District Health Department CASWELL - CHATHAM - LEE - PERSON COUNTIES ' Water SM pply and Sewage Disposal �� ROVEMENTS PERMIT;;allo' ' . Permit y01U after 3 Years Date .:�t"�' �►- `:-�— --..�..�_,r,.. O�.+p*� t��,,�;,_,'�"�"`� v�� ; Location: °�a/` 1/ v� a..� � . Q. Contractor: ' Wates. Supplp: Private Public Seaaqe Disposal Faciliiies: No. bedrooms � I washina mac�+�*+q ^•�-�r sutom tic sppliances Size oi tank: � Nitriflcatioa line: . r.el Other disposal facility: - i Water supply and sewage disposal facilities location, installation arrd i protection must meet state and local regulations. 5eptic tank should be pumped out every 3 to 5 years and shall be maih- tained by owner in such a manneT as not ta create a public health hazard. Septic tank and nitrification line UST BE INSPECTED AND AP PROVED BY A MEMBER OF THE ID�IS�.,'RICT HEALTH:DEPARTMENT STAFF BEFORE ANY POitTION OF THE IJ�$�TION IS COV- ERED AND PidT INTO US& A 1} . .�: Date approved� �-} 8- g g WeA��•' �AIJ�L(A.�_� Sewage Disposal• � Hy. j'�3a �� w.a,' or CestItieate of Complelion . Date Approved: "3Q'� gy• .�� .L7�-,-+�-- I S3nitarisn � (OVER) • ; Location oi well and sewage disposal iscilities sketched ou back. . I �� .� a vi � � ' r+ a a, � � 0 x 0 0 � � � � x �, b � v �N � .� '� O i+ ca � � w �' o � u .� .� a, � H O z _-� _ _.. -�; �.,.� �; i . �, WELL PERMIT Caswell-Chatham-Lee-Person Counties DATE ISSUED. DATE DRILLED: COUNTY: �� D • OWNER:� ✓ ROAD/S T: �/ � ADDRESS:'__, � R NE YEAR ��y�-- DRILLING CONT TOR: i �� - _. . ` _ _.._._--- NAME ADDRESS - WELL CONSTRUCTION Distance from Nearest Property Line Distance from Source of • Pollution Total Depth: . Yield: � GPM Static Water Leve :- Ft. Nater Bearing Zones: th• �i'yt. Ft. Ft. Casing: Depth: From�to �'Ft. Di er:, Inches TYPE: Steel Galvanized Stee1 . If Steel, does owner appro Yes No Weight: Thicknes�: _�Height Above Ground:___Inches Drive Shoe: Yes: No: Were Problems Enccuntered in Setting the Casing? Yes__ No_ If "yes" give reason: ,/ 3rout: Type: Neat Sar�27�ement: _ Concrete � Annular upace Width 1 G�- Inches _ ' ` � Water in Annular Space: Yes No y ; Method: Pumped �¢ ure Poured � Depth: From `' to G,X/ Ft. i Materials Used:, -No. Hags.Portland Cement Weight of � 1 bag ., . lbs�. ,. ' if mixture (sand, gravel, cuttings) - Ratio to ! SD Plates: Yesr o Chlorination `.Yes No �� 4 x 4 slab Yes� No . . . �� . lY . , � i . � nanth .. . . . I . . . . ..� ■ ,. C HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT A D THAT THIS �ELL WAS CONSTRUCTED IN ACCORDANCE GULAT S�SET ORTH BY �ASWELL-CHATfiAM-LEE-PERSON DIST. H T. Sig ature of Contractor Date iketch�well location on reverse side. Use established reference �oints. � Application Date: � ��-c� "�C� Amount Paid: ��00 Receipt #: gT � d 3 � ��1�� Aa Improvement Permit (Site Evaluation) $200.00/$300.00 (if> 600 gpd) Mobile Home Replacement or Building . $150.00 (if site visit required) Well Permit (New/Replacement/Repair) $300.00/$200.00/$75.00 '`� l. ) � �� `L.1i1� � Tax Map: �o�. � _ �—�' ��.��,�� Parcel#: ^ �o% ��.m�.v �ia-aD�en�rna.c:�rnif:�.11 ]I�-3I�,�,.11tG�n ilication for Services Services Re uested Construction Authorization (Fee is deoendent on the tvne of Permit Revision $75.00 Repair of Existing Septic System Application: No Charge/ CA $150.00 or $300.00 1) Applicant Information: Name: � re.►'� da � r �e,►•- Phone (home): 33(� -.�`�'�I - `�3 �7 Address: �}Q o �'� t�� d (work/cell): 33� -S� 3- Stc t� �nX.h�� i��- Z'�� 7`�; 2) Name and address of current owner (if different than applicant): � Name: Phone: Address: �lM. 3) Property Description: Lot Size: ��2�c��v Subdivision: !"�o�w(�.- �a•�G- Lot #: L Address and/or directions to Property: ❑ yes ❑ nb Does the site contain any jurisdictional wetlands? 0 yes ❑ r�o Does the site contain any existing wastewater systems? ❑ yes ❑ o Is any wastewater going to be generated on the site other than domestic sewage? 0 yes � no Is the site subject to approval by any other public agency? O yes no Are there any easements or right of ways on this property? (if `yes' is checked; please provide supporting documentation) 4) Proposed Use and Type of Structure: ❑Residential ❑ New Single Family Residence Maximum number of bedrooms: / Occupants: ❑ Expansion of Existing System If expansion: Current number of bedrooms: ❑ Repair to Malfunctioning System Will there be a basement? ❑ yes ❑ no With plumbing fixtures? ❑Non-Residential Type of business: Maximum number of employees: Total Square footage of Building: Maximum number of seats: � `�� r�� . ►.0 Q %� 6i � � yes ❑ no 5) Water Supply: ❑ New well ❑ Existing Well ❑ Community Well ❑ Public Water ❑ Spring Are there any existing wells, springs, or existing waterlines on this property? ❑ yes ❑ no Please note any known ground water restrictions or sources of contamination: (6) If applying for `Authorization to Construct', please indicate preferred system type(s): � ❑ Conventional � Accepted ❑ Innovative ❑ Alternative � Other ❑ Any 1 certify that the information provided above is complete and correct. 1 also understand that if the information provided is inaccurate, the site is su�iseque�ly altered, or the intended use changes, all permits and approvals shall be invalid. Signature (Owner/ Legal Representative*) * Supporting documentation required. �-a�-i� Date Permits are valid for either 60 months or are non-expiring when accompanied by an approved plat. A completed `Lot Preparation' form must accompany any application requiring a site evaluation. (10/15) Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 (336-597-1790) . � � � . f < �: .� { . :..:.:. .:. � �� .. . ��.�.��,��.�. ��.�.�� Building Additions/ Mobile Home Replacements Tax Map #:� Parcel#: �07 Address: t,�9� .�1c=t��.� .c'-?,� Approval Requested for: Mobile Home Replacement � Building Addition �d X � ` �� j1�,�:n19 Applicant Name: ,; ,�C�/p� � _ Address: Phone #'s: 9 � � ��- �� / !� Permit Located: ►� Yes No Installation Date: � Design flow: ��d (gpd) Current Contract with Certified Operator on file (if required): �_ Water Supply: ✓ Well Public or Community Wastewater system shows no visual evidence of failure on: �,�fv (date) (Applicant's signature if site visit is not required) � _.► �/��J .' . � r. � Addition/Replacement Appa-oved Enviromm �ta He Specialist Z/��i �v Date Person County Environmental Health, 325 S. Morgan St., Suite C, Roxboro, NC 27573 Phone: 336-597-1790/ Fax: 336-597-7808 www.oersoncount,y.net ConnectGIS Feature Report �� : ��'�� 3CMS '.tiEi wC:Stf€!�; 95-1{?9 Page 1 of 1 �-�7 �9D c � C� ✓�,� Person Printed February 02, 2016 See Below for Disclaimer County Environmental Health 325 S. Morgan Street Suite C Roxbo% NC 27573 32� ��;� .� .,�� •`�. �-'r ,,�;�� ;��;r� _l 35J7 ��1 5 ;�, '��f, f,,, ��'�1.� � �iafCE�S ❑ Progress xrEas fl� � Fragre5s �.reas (2� � � Parcel Address �oir�;� � €��rcel Lir,e C}imer�siors Ldk�s � Roads Ciiy of Ra�boro ❑ Volur�'�}r �gric�i�ural Cistric#s t��2o�s�1D , .� S'fbe.s 4� $�wa� ^'� �� x�� ,�l � ; �_ ss 1 , i00 Feet � �_._.�,.,� _ ...,.�,� , , � _..� . -__-____.. , JTICE: Recently, we have had several users report browser compatibility issues when trying to access our GIS website. Typically, the problem stems from users who h cently upgraded to the Windows 8 opereting system or a new version of Internet Explorer. We were able to resolve this issue by directing users to the Internet Expii �mpatibility View tool. This link is to Microsoft's "How To" for the tool: httpJ/windows.microsoft.com/en-US/internet-explorer/products/ie-9/features/compatibility-� this does not solve the problem feel free to contact us at the number listed on our main page. Welcome to the Person County GIS Website. ConnectGlS has b epared for the inventory of real property found within Person County, and is compiled from recorded deeds, plats, and other public records. Users of GIS system �tified that the aforementioned public information sources should be consulted for verification of the information in this system. Person County, Mobile 311, Conned sume no leqal responsibility for the information in this system. Grid is based on the NC state plane coordinate system, 1983 NAD. http://gis.personcounty.net/ConnectGIS v6/DownloadFile.ashx?i=_ags_mapfbcee5fc60e54... 2/2/2016